Public Policy and Politics

Series Editors: Colin Fudge and Robin Hambleton

Public policy-making in western democracies is confronted by new pressures. Central values relating to the role of the state, the role of markets and the role of citizenship are now all contested and the consensus built up around the Keynesian welfare state is under challenge. New social movements are entering the political arena; electronic technologies are transforming the nature of employment; changes in demographic structure are creating heightened demands for public services; unforeseen social and health pro­blems are emerging; and, most disturbing, social and economic inequalities are increasing in many countries.

How governments - at international, national and local levels - respond to this developing agenda is the central focus of the Public Policy and Politics series. Aimed at a student, professional, practitioner and academic reader­ship, it aims to provide up-to-date, comprehensive and authoritative analyses of public policy-making in practice.

The series is international and interdisciplinary in scope, and bridges theory and practice by relating the substance of policy to the politics of the policy­making process.

Public Policy and Politics

Series Editors: Colin Fudge and Robin Hambleton

PUBLISHED Kate Ascher, The Politics of Privatisation: Contracting Out Public Services Rob Atkinson and Graham Moon, Urban Politics in Britain: The City, the

State and the Market Jacqueline Barron, Gerald Crawley and Tony Wood, Councillors in Crisis:

The Public and Private Worlds of Local Councillors Danny Burns, Robin Hambleton and Paul Hoggett, The Politics of

Decentralisation: Revitalising Local Democracy Aram Eisenschitz and Jamie Gough, The Politics of Local Economic Policy:

The Problems and Possibilities of Local Initiative Stephen Glaister, June Burnham, Handley Stevens and Tony Travers,

Transport Policy in Britain Christopher Ham, Health Policy in Britain: The Politics and Organisation of

the National Health Service (fourth edition) Ian Henry, The Politics of Leisure Policy Peter Malpass and Alan Murie, Housing Policy and Practice (fifth edition) Robin Means and Randall Smith, Community Care: Policy and Practice

(second edition) Gerry Stoker, The Politics of Local Government (second edition) Kieron Walsh, Public Services and Market Mechanisms: Competition,

Contracting and the New Public Management

FORTHCOMING Tony Green and Geoff Whitty, The Changing Politics of Education:

Education Policy in Contemporary Britain John Solomos, Racial Inequality and Public Policy

Public Policy and Politics Series Standing Order ISBN 978-0-333-71705-9 hardcover ISBN 978-0-333-69349-0 paperback (outside North America only)

You can receive future titles in this series as they are published. To place a standing order please contact your bookseller or, in the case of difficulty, write to us at the address below with your name and address, the title of the series and the ISBNs quoted above.

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Health Policy in Britain

The Politics and Organisation of the National Health Service

Fourth Edition

Christopher Ham

© Christopher Ham 1982, 1985, 1992, 1999 Softcover reprint of the hardcover 4th edition 1999 978-0-333-76406-0

All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission.

No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London WlP OLP.

Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

The author has asserted his right to be identified as the author of this work in accordance with the Copyright, Designs and Patents Act 1988.

First edition 1982 Second edition 1985 Third edition 1992 Fourth edition 1999

Published by MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world

ISBN 978-0-333-76407-7 ISBN 978-1-349-27706-3 (eBook) DOI 10.1007/978-1-349-27706-3

A catalogue record for this book is available from the British Library.

10987654321 08 07 06 05 04 03 02 01 00 99

Copy-edited and typeset by Povey-Edmondson Tavistock and Rochdale, England

To Joanna

Contents

List of Figures and Tables

Acknowledgements

Preface to the Fourth Edition

Abbreviations

Introduction

1 The Development of Health Services and Health Policy Public health services Mothers and young children Health insurance Hospital services The establishment of the National Health Service The structure of the National Health Service The NHS between 1948 and 1974 The reorganisation of the NHS The reorganised National Health Service Conclusion

2 Health Policy under Thatcher and Major Increasing NHS efficiency Making the NHS businesslike Dealing with the funding crisis Working for Patients The reform of primary care and community care Implementing the reforms The impact of the reforms Streamlining the structure Conclusion

3 New Labour and the NHS The inheritance The new NHS The new structure

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1

4 5 6 7 8

10 12 13 19 21 24

27 27 29 32 35 38 39 45 48 49

51 51 54 57

viii Contents

Implementation 61 Integrated care 64 The comprehensive spending review 66 Northern Ireland, Scotland and Wales 67 Conclusion 70

4 Contemporary Issues in Health Policy 72 The growth of NHS expenditure 72 Raising and spending money in the NHS 76 Public health and health improvement 80 Health care 84 Health and social care 90 Priority-setting 93 Conclusion 96

5 The Policy-making Process in Central Government 97 What is policy? 97 The policy process 99 Limits of the systems model 101 British central government 102 Parliament 104 The Prime Minister and Cabinet 106 Ministers and civil servants 109 Relationships between departments 111 Outside interests 114 Pluralism or corporatism? 115 Conclusion 118

6 Making and Changing Health Policy 120 The Department of Health 120 The policy community 126 The sources of policy inputs 129 Policy analysis in the Department 142 Back to management 145 Conclusion 150

7 Implementing Health Policy 152 The management of the NHS 152 NHS Executive regional offices 153 Health authorities 155 NHS trusts 158 Primary care trusts 159 Special health authorities 160 The role of the DH 160

Professional influences on policy implementation Policy-making in NHS bodies Conclusion

8 Monitoring and Evaluating Health Policy The audit explosion Health improvement Access to health care The NHS in the international context Conclusion

9 Power in Health Services Marxist approaches Pluralism Structuralist approaches Concepts of health Power, interests and ideology Theories and practice Conclusion

Guide to Further Reading

Bibliography

Index

Contents ix

166 170 174

176 176 184 191 197 202

203 203 204 205 207 209 212 216

218

221

231

List of Figures and Tables

Figures

1.1 The structure of the NHS, 1948-74 13 1.2 The structure of the NHS, 1974-82 20 1.3 The structure of the NHS, 1982-91 24 2.1 Hospital and community health services: trends in spending,

targets and shortfalls 33 2.2 The structure of the NHS in England, 1991-96 40 2.3 The structure of the NHS in England, 1996--99 47 3.1 The structure of the new NHS 58 3.2 Levels of primary care groups 59 3.3 A framework for quality 63 3.4 The structure of the NHS in Scotland 68 4.1 Cost of NHS as percentage of GDP, 1949-98 74 4.2 International comparison of expenditures on health care,

1996 75 4.3 Sources of NHS finance, 1997-98 77 4.4 Distribution of NHS budget, 1997-98 77 4.5 Distribution of hospital and community health services

expenditure, 1995-96 78 4.6 Distribution of family health services expenditure, 1996--97 78 4.7 Distribution of health and community health services

expenditure by age group, 1995-96 79 4.8 Expectation of life at birth, EU, 1995 85 5.1 A simplified model of a political system 100 6.1 Structure of the Department of Health 121 6.2 Structure of the NHS Executive 123 7.1 NHS Executive regional office boundaries from 1 April 1999 154 8.1 Percentage survival to 1991 of children born since 1950,

England and Wales 186 8.2 Prevalence of reported limiting long-standing illness by

socioeconomic group, and by age group, Great Britain, 1994 188 8.3 Waiting lists in England and Wales, 1948-96 196 8.4 Health in Europe 198

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List of Figures and Tables XI

Tables

2.1 Background of general managers, 1986 31 2.2 The implementation of GP fundho1ding and NHS trusts 41 4.1 NHS expenditure UK, 1949-96 73 4.2 NHS directly employed staff, 1996, England (WTEs) 79 4.3 A contract for health 83 4.4 The Patient's Charter 86 8.1 NHS performance assessment framework 181 8.2 Life expectancy, England and Wales, 1841-1991 185 8.3 Age-specific mortality rates, by social class, men aged 20-64,

all causes, England and Wales, 1991-93 187 8.4 Comparison of mortality rates per million population in

England and Wales in 1950 and 1994 190 8.5 Percentage shares of NHS expenditure standardised for need,

1974-87 193

Acknowledgements

The author and publishers would like to thank the following who have kindly given permission for the use of copyright material: The University of Chicago Press for a diagram from David Easton, A Systems Analysis of Political Life, 1965; The King's Fund for a figure from Health Finance: Assessing the Options, 1988; The Nuffie1d Trust for a table from Who Pays For and Who Gets Health Care?, 1998; The Economist for a figure from the issue of 12 December 1998; Crown Copyright material is reproduced with the permission of the Controller of Her Majesty's Stationery Office (from Department of Health, The Government's Expenditure Plan 1998-99: Depart­mental Report; Secretary of State for Health, The New NHS: Modern, Dependable; Secretary of State for Health, Our Healthier Nation; Secretary of State for Health, A First Class Service; Secretary of State for Scotland, Designed to Care; F. Drever and M. Whitehead, Health Inequalities; B. Botting, The Health of Our Children; J. Charlton and M. Murphy, The Health of Adult Britain 1841-1994).

Every effort has been made to contact all the copyright-holders, but if any have been inadvertedly ommitted the publishers will be pleased to make the necessary arrangement at the earliest opportunity.

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Preface to the Fourth Edition

This book was originally based on undergraduate and postgraduate courses I taught at Bristol University. The first edition benefited from the comments and suggestions ofthe students who followed those courses. I am particularly grateful to Laurie McMahon and Andrew Wall for their insights, gained during the first intake of the MSc in Public Policy Studies run by the School for Advanced Urban Studies at Bristol. I would also like to thank former colleagues at the School who commented on draft chapters, most notably Robin Hambleton, Michael Hill, Robin Means, Randall Smith and David Towell. Special mention should also be made of Ken Judge, with whom I jointly taught an undergraduate course in health policy. As editor of the series, 'Studies in Social Policy', in which the first two editions appeared, Ken encouraged me to write Health Policy in Britain, and as always was a constructive and critical collaborator.

The fourth edition is based on the same structure as earlier editions but has been completely revised and updated to take account of developments in health services and health policy in the 1990s. I have benefited from the advice and comments of a number of people in the Department of Health and the NHS as well as colleagues at the Health Services Management Centre at the University of Birmingham. I would particularly like to mention the assistance provided by Brigit Ayling and her colleagues in the Centre's library; the support of my assistant, Anne van der Salm; and also the work of Debbie Styer, who incorporated my new text with the original, with the last­minute help of Sue Alleyne and other colleagues. My publisher, Steven Kennedy, was even more patient on this occasion than previously.

Last but not least, I would like to thank Ioanna Burnell for her continuing support. The distractions that writing (and revising) a book inevitably creates intrudes into home life. Once again, I am pleased to dedicate the book to Ioanna.

I alone am responsible for the final text.

Solihull CHRISTOPHER HAM

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Abbreviations

AHA ASH BMA CHC CHI CIP CMO CPRS CSR DCMO DGH DGM DH DHA DHSS DMT DMU FHSA FPC FPS GHS GDP GP HAS HCHS HlmP HMC HMO JCC MAS MPC NAHA NAHAT NAO NICE NHS NHSME

Area Health Authority Action on Smoking and Health British Medical Association Community Health Council Commission for Health Improvement Cost Improvement Programme Chief Medical Officer Central Policy Review Staff Comprehensive Spending Review Deputy Chief Medical Officer District General Hospital District General Manager Department of Health District Health Authority Department of Health and Social Security District Management Team Directly Managed Units Family Health Services Authority Family Practitioner Committee Family Practitioner Services General Household Survey Gross Domestic Product General Practitioner Health Advisory Service Hospital and Community Health Services Health Improvement Programme Hospital Management Committee Health Maintenance Organisation Joint Consultative Committee Management Advisory Service Medical Practices Committee National Association of Health Authorities National Association of Health Authorities and Trusts National Audit Office National Institute for Clinical Excellence National Health Service National Health Service Management Executive

xiv

NHST OECD OHE OPCS PACT PCGs PESC QALY RAWP RCP RGM RHA RHB RL SHA SMR

Abbreviations xv

National Health Service Trusts Organisation for Economic Cooperation and Development Office of Health Economics Office of Population, Censuses and Surveys Prescribing Analysis and Cost System Primary Care Groups Public Expenditure Survey Committee Quality Adjusted Life Year Resource Allocation Working Party Royal College of Physicians Regional General Manager Regional Health Authority Regional Hospital Board Regional Liaison Special Health Authority Standardised Mortality Ratio